In Sweden, 52% of Woman Who Committed Suicide in 2006 Were Taking Antidepressants: APA Letter

Thursday,July30th,2009

Paragraph three reads: "We first looked at antidepressant prescriptions. Of the 776Scandinavian men in the sample, 259 (32%) (age-adjusted 95%confidence interval [CI]=28.5–35.2) filled a prescriptionfor antidepressants in the 180 days before death. The correspondingfigures were 176 of the 333 Scandinavian women in the sample(52%) (CI=46.7–57.5), 32 of the 102 foreign-born men (31%)(CI=21.6–39.5), and 21 of the 44 foreign-born women (43%)(CI=28.7–58.1)."

Letter

To the Editor: In the October 2007 issue Ray and colleagues(1) observed that the odds of receiving treatments for mooddisorders in the year preceding suicide were lower for AfricanAmericans. The study of racial-ethnic differences in drug utilizationamong individuals with severe mood disorders is important. Weanalyzed whether similar undertreatment is present in Sweden,a country of nine million inhabitants. However, because Swedenhas a different racial-ethnic composition than the United States,we analyzed country of birth instead of race.

We analyzed all suicides and deaths from undetermined intentamong persons aged 18 to 84 in 2006 (N=1,255, or about 95% ofall suicides). We examined use of prescription drugs in the180 days before death. Persons born in Sweden, Denmark, andNorway, representing the Scandinavian countries, were comparedwith persons born in all other countries.

We first looked at antidepressant prescriptions. Of the 776Scandinavian men in the sample, 259 (32%) (age-adjusted 95%confidence interval [CI]=28.5–35.2) filled a prescriptionfor antidepressants in the 180 days before death. The correspondingfigures were 176 of the 333 Scandinavian women in the sample(52%) (CI=46.7–57.5), 32 of the 102 foreign-born men (31%)(CI=21.6–39.5), and 21 of the 44 foreign-born women (43%)(CI=28.7–58.1).

We also examined use of antipsychotic drugs. Among Scandinavianmen, 100 (13%) (CI=10.1–14.5) filled a prescription foran antipsychotic in the 180 days before death. The correspondingfigures were 81 of the Scandinavian women (24%) (CI=19.5–28.9),19 of the foreign-born men (18%) (10.7–25.4), and 16 ofthe foreign-born women (32%) (CI=19.8–44.6). Use of lithiumwas 2% or less in all groups.

As a comparison we analyzed use of these drugs among personsaged 18 to 84 years in the Swedish population in 2006 by countryof birth. Among Scandinavian men, 6.1% (CI=6.05–6.10)had at least one filled prescription for an antidepressant.The corresponding figure for foreign-born men was 6.5% (CI=6.43–6.59).Among Scandinavian women the figure was 11.7% (CI=11.68–11.76),compared with 11.1% (CI=11.02–11.20) for foreign-bornwomen. We did not analyze differences in inpatient or outpatientadmission before suicide, although we have previously commentedon postdischarge suicides in Sweden (2).

We have some minor concerns about the study by Ray and colleagues(1). Data used in that study represented suicides in differentperiods­1986 to 2004. Over those years, at least in Sweden,policies in regard to inpatient care changed. We also suspectthat use of antidepressants increased substantially in the UnitedStates since the early 1990s as a result of the introductionof selective serotonin reuptake inhibitors (SSRIs). The increasein use of SSRIs in Sweden was sixfold between 1990 and 2004.In the study by Ray and colleagues, the mean age of AfricanAmericans who committed suicide was also nearly ten years lowerthan that of whites, which may indicate socioeconomic or otherdifferences in the underlying white and African-American populationsfrom which the samples were drawn.

Although one might suspect relative undertreatment of psychiatricdisorders in the non-Scandinavian population in Sweden, it couldnot be verified by our analyses because we studied only drugutilization without knowledge of the underlying disease prevalence.However, the rates of prescription were similar for Scandinaviansand foreign-born persons in our sample who filled a prescriptionfor an antidepressant in the months before they committed suicide­andwho therefore could be said to have been suffering from a severemood disorder. This, together with the observed similar ratesof prescription in the general population, could indicate equalaccess to drug treatment. The study by Ray and colleagues highlightsan important issue in research on socioeconomic inequalitiesin care. Racial-ethnic differences in the use of medicationsmay result from differences in religious and cultural beliefsthat can affect both health-seeking behavior and attitudes towardsuicide.